Every finding on record at Bushwick Center for Rehabilitation and Health Care

Based on record review and staff interviews conducted during a Recertification survey from 06/16/2025 to 06/24/2025, the facility did not ensure that the baseline care plan was developed and implemented within 48 hours of admission. This was evident for 2 (Resident #155 and #202) of 6 residents reviewed for Care Plan out of 38 sampled residents. The findings are: The facility policy titled Care Plans - Baseline with creation 11/2027 and last reviewed date 1/2020 stated that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty- eight (48) hours of admission. 1) Resident #155 was admitted to the facility with diagnoses that included Anxiety disorder, Unspecified organism of sepsis, and Unspecified neuralgia. The admission Minimum Data Set, dated [DATE] documented Resident #155 was cognitively intact, and only Resident #155 participated in the assessment. The document titled Team: IDT (interdisciplinary team) Baseline Care Plan - V 3 for Resident #155 was created on 03/20/2025 and locked on 03/25/2025. There was no documented evidence that the baseline care plan for Resident #155 was developed within 48 hours of their admission. 2) Resident #202 was admitted to the facility with diagnoses that included Major depressive disorder, Anxiety disorder, and Personal history of pulmonary embolism. The admission Minimum Data Set, dated [DATE] documented Resident #202 was cognitively intact, and only Resident #202 participated in the assessment. The document titled Team: IDT (interdisciplinary team) Baseline Care Plan - V 3 was created on 04/17/2025 and locked on 04/25/2025. There was no documented evidence that the baseline care plan for Resident #202 was developed within 48 hours of their admission. On 06/20/2025 at 10:17 AM, Registered Nurse #1 was interviewed and stated the unit nurse managers were responsible to create and oversee the completion of the baseline care plan. Registered Nurse #1 also stated they are supposed to complete the baseline care plan within 48 hours of admission. Registered Nurse #1 reviewed the baseline care plan for Resident #155 and Resident #202 and stated they believed they completed the baseline care plan within 48 hours of admission but did not lock the baseline care plan until more than 2 days later. Registered Nurse #1 also stated the baseline care plan was not considered completed until it was locked in the electronic medical record. On 06/20/2025 at 11:57 AM, the Director of Nursing was interviewed and stated it was documented in facility policy that the baseline care plan had to be completed within 48 hours of admission. The Director of Nursing reviewed the baseline care plans of Resident #155 and Resident #202 and stated the baseline care plans were locked beyond 48 hours of admission and were considered to be completed late. 10 NYCRR 415.11(c)

Based on observations, record review, and staff interviews conducted during the Recertification survey from 06/16/2025 to 06/24/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #147) of 4 residents reviewed for Pressure Ulcer/Injury out of an investigative sample of 38 residents. Specifically, during a wound care observation for Resident #147, Licensed Practical Nurse #5 did not change gloves and sanitize hands after cleaning wound and before applying the treatment and clean dressing to the wound. The findings are: The facility policy titled Hand Hygiene revised 2/19/2025 stated the facility adheres to recommendations by the Centers for Disease Control for the practice of hand hygiene in accordance with standard, enhanced barrier, and transmission-based precautions. The policy further documented Hand hygiene is performed as a minimum at these times: Before and after contact with the resident; Before performing an aseptic task- (for example wound care, etcetera and after contact with objects or surfaces in the resident's room. Resident #147 was last admitted with diagnoses that included Type 2 Diabetes, Hypertension, and Peripheral Vascular Disease. The Quarterly Minimum Data Set, dated [DATE] documented Resident #147 had a diabetic foot ulcer and was receiving treatment. The Physician order reviewed 06/19/2025 documented Calcium Alginate External Miscellaneous (Calcium Alginate) Apply to left distal lateral foot topically every day shift for wound care. Clean with NS, pat dry, apply Calcium Alginate and cover with bordered gauze. On 06/20/2025 at 09:32 AM, Licensed Practical Nurse #5 was observed performing wound care for Resident #147. Licensed Practical Nurse #5 washed hands, donned gloves and removed the old dressing from the wound on Resident #147's left foot. Licensed Practical Nurse #5 then removed gloves, washed hands and donned gloves. Licensed Practical Nurse #5 cleansed the wound with gauze down the sides and the middle the wound each with different gauze. Licensed Practical Nurse #5 did not perform hand hygiene or don clean gloves and then applied the Calcium Alginate treatment, placed a clean dressing on the wound, and entered the date. Licensed Practical Nurse #5 then discarded the garbage, removed gown and gloves, and washed hands. On 06/20/2025 at 10:03 AM, Licensed Practical Nurse #5 was interviewed and stated they work with the wound doctor weekly to do wound rounds throughout the facility. Licensed Practical Nurse #5 also stated after cleaning Resident #147's wound, they are supposed to remove gloves, wash hands, donned new gloves and then apply the clean dressing to the wound. Licensed Practical Nurse #5 also stated they were trained on proper handwashing in-between tasks and knows the process. Licensed Practical Nurse #5 further stated they very nervous because they were being observed. On 06/20/2025 at 10:38 AM, the Assistant Director of Nursing who is the Infection Preventionist for the facility was interviewed, and stated the staff are trained on infection control and while there was not a set schedule for training, they retrain the staff if a situation comes up. The Infection Preventionist also stated training in Infection Control is done at least annually, upon hire and throughout out the year, as well as in-services on different topics. The Infection Preventionist further stated all staff get in-services on wound care, but the staff who works with the wound doctor have wound certification. The Infection Preventionist stated the staff will perform hand hygiene at the start of wound care, and after removing the soiled dressing will place gloves on washed hands and then clean the wound. The staff will then remove gloves after cleaning the wound, wash hands, don gloves and apply a clean dressing to site. The Infection Control Preventionist also stated based on the observation, the nurse did not follow the protocol of washing hands after removing the soiled dressing and before cleaning the wound and applying the treatment and a clean dressing. On 06/24/2025 at 02:02 PM, the Director of Nursing was interviewed and stated all nurses had at least yearly in-service/training for wound care. 10 NYCRR 415.19 (a)(1),(b)(4)

Based on record review and interviews conducted during the Recertification from 06/16/2025 to 06/24/2025, the facility did not ensure physician's order for code status matched the Medical Orders for Life-Sustaining Treatment form in the medical record. This was evident for 1 (Resident #230) of 1 resident reviewed for Death out of a sample of 38 residents. Specifically, the Physician Order in the electronic health record documented Resident #230's code status as full code and the Medical Orders for Life-Sustaining Treatment form documented Do Not Attempt Resuscitation and Do Not Intubate for Resident #230. The findings include: The policy and procedure titled Advance Directives revised 11/6/2023 and reviewed 5/2025 stated medical orders will be documented in the electronic health record to reflect the resident's code status and any restrictions to intubation and hospitalization, based on the resident's Medical Orders for Life-Sustaining Treatment. Medical Orders for Life-Sustaining Treatment forms should be reviewed and signed by the healthcare provider initially, quarterly, and as needed. The policy and procedure titled Physician Order's revised 2/2020 stated it is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law. Physician orders will be dated and signed according to the state and federal regulations. Resident #230 had diagnoses which included Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 3, and Cerebral Infarction. The admission Minimum Data Set Assessment (a resident assessment tool) dated March 12, 2025, documented Resident #230 had a Brief Interview for Mental Status score of 10 indicating moderately impairment, was able to understand. The March 6, 2025, Medical Orders for Life-Sustaining Treatment form documented Do Not Resuscitate and Do Not Intubate. A review of the physician orders, hard chart, and electronic medical record on 06/20/2024 revealed no physician orders for Resident #230 which documented Resident #230's code status as Do Not Attempt to Resuscitation and Do No Intubate. On 06/23/25 at 08:45 AM, Social Worker #1 was interviewed and stated they are responsible for assisting and initiating with the Medical Orders for Life-Sustaining Treatment on the day of admission. Social Worker #1 also stated Resident #230 signed the Medical Orders for Life-Sustaining Treatment form on 03/06/2025 and if an order is needed, it is the responsibility of the nursing department. On 06/23/25 at 09:13 AM, the Director of Nursing was interviewed and stated when there is a Medical Orders for Life-Sustaining Treatment and/or Advance Directives is to be created, it is the responsibility of the doctor or the Nurse Practitioner to see that the order was carried out and placed into the system. The Director of Nursing also stated the nurse manager/supervisor of the unit that day did the Medical Orders for Life-Sustaining Treatment form with the Social Worker and then gave it to another unit manager who said that they would put in the order for the Resident #230 code status. This did not happen and there was no follow up to see that the code status order was put into the computer system. The Director of Nursing further stated there should have been a physician order for Resident #230's code status. On 06/23/2025 at 09:16 AM, Registered Nurse #2 who was the Nurse Manager/Supervisor on the unit was interviewed and stated Resident #230 was seen with the Social Worker the day after admission to discuss the Medical Orders for Life-Sustaining Treatment form. Registered Nurse #2 also stated the form was explained to Resident #230, who expressed that they wanted to select the Do Not Resuscitate/Do Not Intubate option. Registered Nurse #2 further stated the Medical Orders for Life-Sustaining Treatment form was signed by the Nurse Practitioner, and normally they would put in the order but then they got busy, and the Unit Manager stated they would put in the order. Registered Nurse #2 stated they did not follow up to see if the order was put into the computer. On 06/23/2025 at 09:30 AM, Registered Nurse #3 who was the Unit Manager was interviewed and stated that Medical Orders for Life-Sustaining Treatment forms are initiated on admission and the admitting nurse is responsible for completing the Medical Orders for Life-Sustaining Treatment form and entering an order into the electronic health record for the physician to sign. Registered Nurse #3 also stated when they come in the next day, they review charts to make sure everything is correct. Registered Nurse #3 further stated they vaguely remembered Resident #230, but whoever signed the Medical Orders for Life-Sustaining Treatment form is responsible for entering the order. On 06/23/25 at 09:45 AM, Nurse Practitioner #1 was interviewed and stated once a Medical Orders for Life-Sustaining Treatment form is signed, it is the nurse who enters the order under the provider's name and the provider will review the order and sign off on it. Nurse Practitioner #1 also stated they did not recall if there was an order entered for Resident #230, and if there was not, it could have been a lapse or an oversight. Nurse Practitioner #1 further stated they review the Medical Orders for Life-Sustaining Treatment to make sure it matches the order entered, but they do not know what happened in this instance and why this was not done. On 06/24/25 at 12:56 PM, the Medical Director was interviewed and stated that usually the code status is discussed with the family, and the Medical Orders for Life-Sustaining Treatment form is filled out and the order gets updated. The Medical Director also stated that there may be changes Medical Orders for Life-Sustaining Treatment form and the order may not get updated. The Medical Director further stated the Medical Orders for Life-Sustaining Treatment form supersedes any Medical Doctors order, and staff would look at that first when making treatment decisions in the event of a code. 10 NYCRR 415.3(e)(1)(ii)

Based on record review and interviews conducted during the Recertification survey from 06/16/2025 to 06/24/2025, the facility did not ensure that a comprehensive assessment of a resident was conducted in accordance within the required timeframes. This was evident for 12 (Residents # 151, #134, #179, #4, #34, #62, #151, #120, #27, #97, #158, and #43) out of 28 residents reviewed during the Resident Assessment Facility Task. Specifically, the Admission, Annual and Significant Change assessments were not completed within 14 days of the Assessment Reference Date. The findings include but are not limited to: The facility policy titled Minimum Data Set Assessment 3.0 dated effective 10/1/2019 stated it is the facility policy to follow the guidelines of the state specific Resident Assessment Instrument manual correctly and effectively according to Centers for Medicare & Medicaid. Resident assessments will be conducted and submitted to iQIES in accordance with the state and federal timeframes. 1. The Significant Change Minimum Data Set 3.0 assessment for Resident #151 with an Assessment Reference Date of 02/10/2025 had a documented completion date of 03/25/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the Minimum Data Set assessment with a target date of 02/10/2025 for Resident #151 was completed late, more than 14 days after the Assessment Reference Date. 2. The admission Minimum Data Set assessment for Resident #134 with an Assessment Reference Date of 11/17/2024 had a documented completion date of 12/18/2024. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the Minimum Data Set assessment with a target date of 11/17/2024 for Resident #134 was completed late, more than 14 days after the Assessment Reference Date. 3. admission Minimum Data Set assessment for Resident #179 with an Assessment Reference Date of 05/02/2025 had a documented completion date of 06/14/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the Minimum Data Set assessment with a target date of 05/02/2025 for Resident #179 was completed late, more than 14 days after the Assessment Reference Date. 4. The Annual Minimum Data Set assessment for Resident # 4 with an Assessment Reference Date of 11/04/2024 had a documented completion date of 12/01/2024. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the Minimum Data Set assessment with a target date of 11/04/2024 for Resident #4 was completed late, more than 14 days after the Assessment Reference Date. On 06/20/2025 at 02:43 PM, the Minimum Data Set Assessor was interviewed and stated the target date to complete the Minimum Data Set is seven days from the Assessment Reference Date to submit to Centers for Medicare & Medicaid Services. The Minimum Data Set Assessor also stated the Minimum Data Set was late secondary to being completed late. The Minimum Data Set Assessor gave no reason why the Minimum Data Set was completed late and submitted late. On 06/23/2025 at 10:50 AM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for scheduling the Minimum Data Set assessments, running reports for completion, and overseeing the Minimum Data Set department. The Minimum Data Set Coordinator also stated the Minimum Data Sets books were late because they were not done on time secondary to not having enough time to complete the books. The Minimum Data Set Coordinator further stated they monitor for timely completion by running reports and stated they are aware of the late completion and submission in the facility. The Minimum Data Set Coordinator stated the Minimum Data Set Department is doing their best to complete and submit each Minimum Data Set assessment timely. The Minimum Data Set Coordinator gave no specific reason why the Minimum Data Set assessments were completed and submitted late to the Centers for Medicare & Medicaid Services. On 06/23/2025 at 11:28 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator just informed them that the Minimum Data Set assessment were late. The Administrator also stated they spoke to the Minimum Data Set Coordinator, and they are not sure why the Minimum Data Set assessments were submitted late. 10 NYCRR 415.11(a)(3)(i)

Based on record review and interviews during the Recertification Survey conducted from 06/16/2025 to 06/24/2025, the facility did not ensure timely completion of each resident's quarterly review assessments. This was evident for 28 (Residents #105, #151, #6, #196, #123, #43, #134, #87, #201, #62, #199, #97, #158, #171, #197,#179, #60, #3, #94, #34, #184, #55, #93, #21, #4, #120, #27 and #181) of 28 residents reviewed during the Resident Assessment Facility Task. Specifically, the resident's Quarterly Minimum Data Set assessments were not completed within 14 days of the Assessment Reference Date. The findings include but are not limited to: The facility policy titled Minimum Data Set Assessment 3.0 dated effective 10/1/2019 no review or revised dated noted documented it is the policy of Centers Health to follow the guidelines of the most state specific Resident Assessment Instrument manual correctly and effectively according to Centers for Medicare & Medicaid. Resident assessments will be conducted and submitted iQIES in accordance with the state and federal timeframes. 1. The Quarterly Minimum Data Set assessment for Resident #196 with an Assessment Reference Date of 02/10/2025 had a documented completion date of 03/27/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented Message: Warning Assessment completed late. Assessment date is more than 14 days after the reference date. 2. The Quarterly Minimum Data Set assessment for Resident #62 with an Assessment Reference Date of 05/02/2025 had a documented completion date of 06/14/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented Message: Warning Assessment completed late. Assessment date is more than 14 days after the reference date. 3. The Quarterly Minimum Data Set assessment for Resident #3 with an Assessment Reference Dated of0 5/04/2025 had a documented completion dated of 06/18/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented Message: Warning Assessment completed late. assessment dated is more than 14 days after the reference date. The Minimum Data Set assessments had been completed more than 14 days after the Assessment Reference Date. On 06/20/2025 at 02:43 PM, the Minimum Data Set Assessor was interviewed and stated the target date to complete the Minimum Data Set is seven days from the Assessment Reference Date to submit to Centers for Medicare & Medicaid Services. The Minimum Data Set Assessor also stated the Minimum Data Set was late secondary to being completed late. The Minimum Data Set Assessor gave no reason why the Minimum Data Set was completed late and submitted late. On 06/23/25 at 10:50 AM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for scheduling the Minimum Data Set assessments, running reports for completion, and overseeing the Minimum Data Set department. The Minimum Data Set Coordinator also stated the Minimum Data Sets books were late because they were not done on time secondary to not having enough time to complete the books. The Minimum Data Set Coordinator further stated they monitor for timely completion by running reports and stated they are aware of the late completion and submission in the facility. The Minimum Data Set Coordinator stated the Minimum Data Set Department is doing their best to complete and submit each Minimum Data Set assessment timely. The Minimum Data Set Coordinator gave no specific reason why the Minimum Data Set assessments were completed and submitted late to the Centers for Medicare & Medicaid Services. On 06/23/2025 at 11:28 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator just informed them that the Minimum Data Set assessment were late. The Administrator also stated they spoke to the Minimum Data Set Coordinator, and they are not sure why the Minimum Data Set assessments were submitted late. 10 NYCRR 415.11(a)(4)

Based on record review and interviews during the Recertification Survey conducted from 06/16/2025 to 06/23/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident for 7 (Residents #6, #134, #123, #97, #181, 105 and 34 ) out of 28 residents reviewed for the during the Resident Assessment Facility Task. Specifically, Residents #6, #134, #123, #97, #181, #105 and #34's Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings include but are not limited to: The facility policy titled Minimum Data Set Assessment 3.0 dated effective 10/1/2019 no review or revised dated noted documented it is the policy of Centers Health to follow the guidelines of the most state specific Resident Assessment Instrument manual correctly and effectively according to Centers for Medicare & Medicaid. Resident assessments will be conducted and submitted iQIES in accordance with the state and federal timeframes. 1. The Quarterly Minimum Data Set assessment for Resident #105 with an Assessment Reference Date of 01/31/2025 had a documented submission date of 03/15/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the submission date is more than 14 days after this new assessment. 2. The Quarterly Minimum Data Set assessment for Resident #123 with an Assessment Reference Date of 01/29/2025 had a documented submission date of 03/05/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the submission date is more than 14 days after this new assessment. 3. The Annual Minimum Data Set assessment for Resident #34 with an Assessment Reference Date of 01/23/2025 had a documented submission date of 06/18/2025. The Centers for Medicare & Medicaid Services Minimum Data Set 3.0 Nursing Home Final Validation Report documented the submission date is more than 14 days after this new assessment. On 06/20/2025 at 02:43 PM, the Minimum Data Set Assessor was interviewed and stated the target date to complete the Minimum Data Set is seven days from the Assessment Reference Date to submit to Centers for Medicare & Medicaid Services. The Minimum Data Set Assessor also stated the Minimum Data Set was late secondary to being completed late. The Minimum Data Set Assessor gave no reason why the Minimum Data Set was completed late and submitted late. On 06/23/2025 at 10:50 AM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for scheduling the Minimum Data Set assessments, running reports for completion, and overseeing the Minimum Data Set department. The Minimum Data Set Coordinator also stated the Minimum Data Sets books were late because they were not done on time secondary to not having enough time to complete the books. The Minimum Data Set Coordinator further stated they monitor for timely completion by running reports and stated they are aware of the late completion and submission in the facility. The Minimum Data Set Coordinator stated the Minimum Data Set Department is doing their best to complete and submit each Minimum Data Set assessment timely. The Minimum Data Set Coordinator gave no specific reason why the Minimum Data Set assessments were completed and submitted late to the Centers for Medicare & Medicaid Services. On 06/23/2025 at 11:28 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator just informed them that the Minimum Data Set assessment were late. The Administrator also stated they spoke to the Minimum Data Set Coordinator, and they are not sure why the Minimum Data Set assessments were submitted late. 10 NYCRR 415.11

Based on interview and record review conducted during an Abbreviated Survey (NY00377880), on the facility ), the facility did not ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency). This was evident for one (1) out of seven (7) residents (Resident #5) reviewed for falls. Specifically, Resident #5 was observed on the floor into their room on [DATE] at 10:30 AM unresponsive, without vital signs, and a hematoma on their forehead. 911 was called and Resident #5 was pronounced by the emergency service team at 11:16 AM on [DATE]. Registered Nurse Supervisor #1 did not report the unwitnessed fall and injury to the Administrator and the fall was not reported to the New York State Department of Health. The findings include: The facility Policy and Procedure titled Accident- Incidents dated 06/2024 document an incident is any occurrence not consistent with the routine operation of the center. The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse, neglect, and mistreatment or injury of unknown origin. The incident may be a theft or misappropriation of resident property. The Nursing Supervisor/Charge Nurse, is responsible for assessing, reviewing, documenting and reporting of the incident and or accident. The Director of Nursing and Administrator are responsible to review incident/investigation and Conclusion to determine if incident requires reporting to outside agencies such as Department of Health etc. Resident #5 was admitted to the facility with diagnoses including Neoplasm of Lung, Neoplasm of Prostrate, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease. The Minimum Data Set (a resident assessment tool) dated [DATE] documented that Resident #1 had intact cognition. Record review and interviews with Registered Nurse #1 and Licensed Practical Nurse #1 revealed that on [DATE] at 10:30 AM Resident #5 was observed lying on the floor face down and unresponsive in their room. Resident #5 also had a hematoma on their forehead. 911 was called at 10:30 AM and the emergency medical team and the New York Fire Department arrived at the facility at 10:40 AM and took over the code. Resident #5 was pronounced at 11:16 AM by the emergency medical team. Registered Nurse Supervisor #1 stated that Resident #5's fall was not reported to the Director of Nursing, nor the Administrator and they did not initiate an investigation into the fall. The Intake Information dated [DATE] at 3:45 PM revealed that this incident was reported by Resident #5's next of kin (complainant). The complainant reported to the Department of Health that the facility called them and reported that Resident #5 had just died after being found unresponsive. The complainant reported that when they unzipped the bag, they immediately saw a bruising on Resident #5's head and blood on their face. The nursing home was unable to explain the blood and bruising. An autopsy was ordered by the family. Review of the Accident/Incident Reports from [DATE] to [DATE], revealed there were no incident report related to Resident #5 being found unresponsive on the floor in their room on [DATE]. According to the Forensic Pathologist and Neuropathologist Pathology findings dated [DATE]: Resident #5's cause of death was due to Bronchogenic lung adenocarcinoma, hypertension, and emphysema with congestive heart failure. The report also documented Resident #5 had a slight contusion measured one-half inch and a superficial laceration measured less than one-quarter inch and that there was no evidence of significant trauma. During an interview with the complainant on [DATE] at 10:02 AM, the compliant stated they were unsure of staff names, but that they received a call from a facility staff who stated that Resident #5 was found unconscious and cardiopulmonary resuscitation was initiated. The complainant stated they received another call from a staff stating Resident #5 died. The complainant stated within fifteen minutes they arrived at the facility and Resident #5 was in a body bag. The complainant stated that when the staff opened the body bag, they saw a bruise and blood on Resident #5's face and forehead. The complainant stated that the staff was not able to explain the injury. The complainant stated that they took pictures and requested for an autopsy to be done. During a telephone interview on [DATE] at 1:40 PM, Registered Nurse Supervisor #1 stated Resident #5 was found face down on the floor next to their bed unresponsive, and pulseless, by Licensed Practical Nurse #1 at 10:30 AM on [DATE]. Registered Nurse Supervisor #1 stated Resident #5 was observed with a hematoma on their forehead. Registered Nurse Supervisor #1 stated cardiopulmonary resuscitation was initiated by Licensed Practical Nurse #1 and Nurse Practitioner #1 and 911 was called at 10:30 AM. The emergency medical team and the New York Fire Department arrived at 10:40 AM and took over the code. Resident #5 was pronounced at 11:16 AM by the emergency medical team. Registered Nurse Supervisor #1 stated that Resident #5's fall was not reported to the Director of Nursing, nor to the Administrator and they did not initiate an investigation into the fall. During an interview on [DATE] at 3:30 PM, the Director of Nursing stated that they were not in the facility on [DATE] and was not notified of the fall and injury. The Director of Nursing stated they were notified that 911 was called and that Resident #5 was pronounced in the facility. The Director of Nursing stated because they were not aware of the fall, the fall incident was not reported to the New York State Department of Health. During a telephone interview on [DATE] at 1:20 AM, the Administrator stated they were not aware of the fall or that Resident #5 sustained injury. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during an Abbreviated Survey (NY00377880), the facility failed to investigate a fall accident that had resulted in injuries. This was evident for one (1) out of seven (7) residents (Resident #5) reviewed for falls. Specifically, on [DATE] at 10:30 AM Licensed Practical Nurse #1 observed Resident #5 lying face down on the floor next to their bed unresponsive, and without vital signs. Resident #5 also had a hematoma to their forehead. cardiopulmonary resuscitation was initiated and 911 was called. Resident #5 was pronounced at 11:16 AM by the Emergency Medical Team. Registered Nurse Supervisor #1 did not investigate the unwitnessed fall and injury to rule out care plan violation. The findings include: The facility policy and procedure titled Accident- Incidents dated 06/2024 document an incident is any occurrence not consistent with the routine operation of the center. The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse, neglect, and mistreatment or injury of unknown origin. The incident may be a theft or misappropriation of resident property. The Nursing Supervisor/Charge Nurse, is responsible for assessing, reviewing, documenting and reporting of the incident and or accident. The Director of Nursing and Administrator are responsible to review the incident/investigation and conclusion to determine if incident requires reporting to outside agencies such as Department of Health etc. Resident #5 was admitted to the facility with diagnoses including Neoplasm of Lung, Neoplasm of Prostrate, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease. The Minimum Data Set (a resident assessment tool) dated [DATE] documented that Resident #1 had intact cognition. The Intake Information dated [DATE] at 3:45 PM revealed that this incident was reported by Resident #5's next of kin (complainant). The complainant reported to the Department of Health that the facility called them and reported that Resident #5 had just died after being found unresponsive. The complainant reported that when they unzipped the bag, they immediately saw a bruising on Resident #5's head and blood on their face. The nursing home was unable to explain the blood and bruising. An autopsy was ordered by the family. Review of the Accident/Incident Reports from [DATE] to [DATE], revealed there were no incident report related to Resident #5 being found unresponsive on the floor in their room on [DATE]. According to the Forensic Pathologist and Neuropathologist Pathology findings dated [DATE]: Resident #5's cause of death was due to Bronchogenic lung adenocarcinoma, hypertension, and emphysema with congestive heart failure. The report also documented Resident #5 had a slight contusion measured one-half inch and a superficial laceration measured less than one-quarter inch and that there was no evidence of significant trauma. During an interview with the complainant on [DATE] at 10:02 AM, the compliant stated they were unsure of staff names, but that they received a call from a facility staff who stated that Resident #5 was found unconscious and cardiopulmonary resuscitation was initiated. The complainant stated they received another call from a staff stating Resident #5 died. The complainant stated within fifteen minutes they arrived at the facility and Resident #5 was in a body bag. The complainant stated that when the staff opened the body bag, they saw a bruise and blood on Resident #5's face and forehead. The complainant stated that the staff was not able to explain the injury. The complainant stated that they took pictures and requested for an autopsy to be done. During a telephone interview on [DATE] at 1:40 PM, Registered Nurse Supervisor #1 stated Resident #5 was found face down on the floor next to their bed unresponsive, and pulseless, by Licensed Practical Nurse #1 at 10:30 AM on [DATE]. Registered Nurse Supervisor #1 stated Resident #5 was observed with a hematoma on their forehead. Registered Nurse Supervisor #1 stated cardiopulmonary resuscitation was initiated by Licensed Practical Nurse #1 and Nurse Practitioner #1 and 911 was called at 10:30 AM. The emergency medical team and the New York Fire Department arrived at 10:40 AM and took over the code. Resident #5 was pronounced at 11:16 AM by the emergency medical team. Registered Nurse Supervisor #1 stated that Resident #5's fall was not reported to the Director of Nursing, nor to the Administrator and they did not initiate an investigation into the fall. During an interview on [DATE] at 3:30 PM, the Director of Nursing stated that they were not in the facility on [DATE] and was not notified of the fall and injury. The Director of Nursing stated they were notified that 911 was called and that Resident #5 was pronounced in the facility. During a telephone interview on [DATE] at 1:20 AM, the Administrator stated they were not aware that Resident #5 had fallen and sustained injuries. 10 NYCRR 483.12(c)(4)

Based on observation, interview, and record review conducted during the recertification survey from 7/31/2023 to 8/7/2023, the facility did not ensure food was prepared in accordance with professional standards of food safety. This was evident during the Kitchen observation. Specifically, staff were observed not performing hand hygiene during food preparation. The findings are: A facility policy titled Personal Hygiene dated 6/2019 documented when to wash hands: immediately before engaging in food preparation, including working with exposed food, clean equipment, or service utensils, after handling soiled equipment, during food preparation, and as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, after engaging any other activity that contaminates the hands and before putting on single-use durable non-absorbent gloves for working with food. Use of disposable gloves: gloves are to be worn whenever handling food directly; anytime a gloved hand touches a contaminated surface, the glove must be changed, and gloves are to be changed following this procedure: remove glove from one hand using the other hand, peel glove from wrist of covered hand turning the dirty glove side inside, discard soled gloves and wash hands following hand washing policy. During the initial tour of the kitchen, an observation was made on 8/2/2023 at 11:13 AM, Dietary Aide (DA) put on gloves, went into the walk-in refrigerator, and came out with multiple loaves of bread. The DA took off their gloves and went to get a pan of ice for their station. The DA donned new gloves without washing their hands. The DA handled a date gun and then, without changing gloves or sanitizing their hands, the DA began placing donuts inside small plastic containers. An interview was conducted with the DA on 8/2/2023 at 11:17 AM who stated they received training on handwashing, wearing of gloves and infection control. The DA stated they change their gloves often and every time they leave their station. Staff must wash hands before putting on gloves. The DA stated that they believed they washed their hands in between glove changes when they handled the date gun. On 8/7/2023 at 2:55 PM, the Director of Nursing (DNS) was interviewed and stated all staff are in-serviced on infection control, when to use gloves, and when to remove the gloves and wash hands. The DNS stated this is not an ongoing issue in the facility and handwashing competencies are always done with all staff. 415.14(h)

Based on observations, interviews and record review conducted during the Recertification and Complaint (NY00317743) Survey from 07/31/2023 thru 08/07/2023, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 4 Units (Units 2N, 3N, 4L, and 4N) of 6 Units. This was evident during environmental observation. Specifically, 1) Unit 3N was observed with missing closet doors, resident room furniture with broken paneling, a torn and stained mattress cover, dining room chair missing an armrest, mildew stains on the shower chair, missing ceiling tiles in the shower, loose shower room faucet, and stained blood pressure (BP) machines and feeding pump poles, and 2) Units 2N, 4L, and 4N were observed with walls with peeling paint and wheelchairs, recliners, and chairs at the nursing station and in the dining room with torn padding. The findings are: The policy titled Cleaning and Disinfecting Resident Care Items and Equipment dated 5/18/2023 documented shared resident care items and equipment shall be cleaned disinfected between each resident and use. 1.) On 07/31/2023 at 9:30 AM on Unit 3N, the following were observed: a. room [ROOM NUMBER] had a missing closet door. b. room [ROOM NUMBER] had brown dried stains on the feeding pump and pole base. The bedside table was heavily worn exposing the inner corking along the top edges. c. room [ROOM NUMBER] had a missing closet door. The mattress cover leaning against the doorless closet was heavily stained and torn. d. The nursing station desk was missing large pieces of paneling along the sides and top edges. e. 2 swivel chairs at the nursing station had seat cushions that were heavily soiled and spotted with stains. f. the resident dining room had a green chair missing the left arm rest and dining room tables with heavily worn wooden legs. On 08/01/2023 at 9:45 AM, the shower room on Unit 3N was observed with the following: h. large rectangular opening in the ceiling above the shower stall and stained, dirty shower curtains. i. mildew stains along the frame of the small shower chair and black hairs on the seat of the shower chair. j. The sink faucet was movable and loose. k. The floor to the shower stall was noted with a black substance all along the caulking. The Certified Nurse Aide (CNA) # 1 was interviewed on 08/07/2023 at 9:45 AM and stated they were not ware resident rooms on Unit 3N were missing closet doors. CNA #1 did not report missing closet doors to the nurse. CNA #1 stated they should have reported to the nurse that resident rooms were missing closet doors. Shower chairs are cleaned after each use and washed with soap and water. The Licensed Practical Nurse (LPN) # 1 was interviewed on 08/07/2023 at 9:51 AM and stated that the shower chairs are to be wiped down after each use with the germicidal wipes. LPN # 1 stated that the closet doors were removed because the residents would rip them off. Housekeeper # 1 assigned to Unit 3 N was interviewed on 08/07/2023 at 09:58 AM and stated they are responsible for cleaning the unit floors, and shower rooms floors and toilets but not shower chairs. The Acting Housekeeping Director was interviewed on 08/07/2023 at 10:29 AM and stated they make random rounds to ensure that housekeeping staff are doing their jobs. The shower chairs are cleaned by the evening housekeeper twice a month, together with the wheelchairs. The shower chairs are either power washed or washed manually with disinfectant. Housekeeping is also responsible for cleaning the BP machines and feeding pump stands. On 08/07/2023 at 10:39 AM, the Director of Maintenance (DOM) was interviewed and stated they perform daily rounds to observe for broken furniture. The former Director of Nursing (DON) instructed the DOM to remove the closet doors due to behavior issues with the residents. There was a leak in the shower room that damaged the ceiling tiles last week. They had to cut open the ceiling tile to look at the piping. They should have covered the ceiling when they were done. The Dom is still working on the leak. The DON was interviewed on 08/07/23 at 11:33 AM and stated that if a resident has behavior issues such as ripping out the closet door it needs to be care planned for and documented. There is no documented evidence about these two residents exhibiting these behaviors. The shower chairs are to be disinfected after each use by the CNAs and housekeeping also disinfects them in the evening. 42101 2) Between 07/31/2023 at 10:07 AM and 08/03/23 and 12:30 PM, the following was observed on Unit 2N, 4L, and 4N: - room [ROOM NUMBER] a resident bed footboard damaged. - room [ROOM NUMBER] with a wheelchair with ripped cushion. - room [ROOM NUMBER] a green chair with gauges in the cushioning and stuffing showing. - room [ROOM NUMBER] with chipped paint, exposed dry wall, spackled unpainted areas, and a torn window screen. - room [ROOM NUMBER] with room door missing paint. - 4L Nursing station chair with torn cushion and stuffing visible and chipped wood on the desk. - room [ROOM NUMBER] with peeling paint on the walls and 2 recliners with torn cushioning. - room [ROOM NUMBER] with peeling wall paint, dry wall exposed, and a green chair with torn cushioning. - room [ROOM NUMBER] had mismatched paint in the bathroom. On 08/04/2023 at 03:15 PM, Licensed Practical Nurse (LPN) #7 was interviewed and stated that they have noticed the chairs in disrepair at the nursing station. On 08/07/2023 at 11:16 AM, the Maintenance Worker (MW) was interviewed and stated that they do maintenance on all the units. Holes in walls are patched to get ready to repair holes in wall to paint the wall. After patching, they paint. There is no timeframe to complete painting. There is chipped paint on the doors periodically and when they notice, the MW will come up and paint the door. MW is not sure the last time they looked at the need for painting. On 08/07/2023 at 01:55 PM, an interview was conducted with the Director of Maintenance (DOM) who stated painting is done daily as needed. They also do annual check of the complete building for painting needs. They do rounds daily and look for rooms that need painting. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that the comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. This was evident for 2 (Resident #13 and #47) of 38 total sampled residents. Specifically, 1) Resident #13's CCP related to risk for infection related to indwelling catheter, constipation related to bowel obstruction, alteration in physical function related to traumatic spinal cord injury, paraplegia, bladder spasm, ostomy appliance related to bowel obstruction, and impaired gastrointestinal function related to constipation were not reviewed upon assessment, and 2) Resident #47's CCP related to alteration in physical function, and bowel incontinence related to Cerebrovascular Accident (CVA) with hemiparesis were not reviewed upon assessment. The findings are: The facility policy titled Care Plans - Comprehensive dated 10/2019 documented CCPs are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the CCP at least quarterly with scheduled Minimum Data Set 3.0 (MDS). 1) Resident #13 had diagnoses of paraplegia and colostomy status. The MDS dated [DATE] documented Resident #13 had mild cognitive impairment, had an indwelling catheter, and had an ostomy. Physician's Orders dated 9/12/2022 documented clean Resident #13's Suprapubic site with normal saline cover with dry dressing every night shift and as needed for Suprapubic site care, dated 7/29/2021 documented Lactobacillus Capsule 1 capsule by mouth one time a day for Probiotic, dated 7/28/2021 documented Oxybutynin Chloride Tablet 5 MG 1 tablet by mouth three times a day for Bladder spasms, dated 11/4/2021 documented Suprapubic Care every shift for Neuromuscular Dysfunction of the Bladder, and dated 11/4/2021 documented urine output every shift. A CCP related to Resident #13's Alteration in physical function r/t Traumatic spinal cord injury, paraplegia, Bladder spasm created 1/16/2019 documented the last revision date was 4/7/2022. A CCP titled Constipation related to Resident #13's bowel obstruction created 1/16/2019 documented no review or revision date since 1/16/2019. A CCP titled Ostomy appliance (Colostomy) related to Resident #13's bowel obstruction created 1/14/2019 documented the last review date as 2/10/2022. A CCP titled impaired gastrointestinal (GI) function related to Resident #13's Constipation created 5/16/2017 documented the last review date as 8/13/2018. A CCP titled at risk for infection related to Resident #13's (Suprapubic) Indwelling catheter created 1/17/2019 documented the last review date as 2/10/2022. There was no documented evidence Resident #13's CCPs related to ostomy, indwelling catheter, bowel and bladder were reviewed and/or revised at east quarterly in accordance with the MDS assessment dated [DATE]. 2) Resident #47 had diagnoses of cerebral vascular accident (CVA) with left hemiplegia and noninfective gastroenteritis and colitis. The MDS assessment dated [DATE] documented Resident #47 was cognitively intact and had hemiplegia. Physician's Orders related to Resident #47's constipation was documented as the following: Bisacodyl Tablet Delayed Release 5mg 2 tablets twice a day initiated 11/17/2022, Docusate Sodium Capsule 100mg 1 capsule twice daily initiated 11/17/2022, Glycolax Powder give 17 grams daily initiated 11/18/2022, Sennosides Tablet 8.6 MG Give 2 tablets twice daily initiated 11/17/2022, Linzess 72 mcg. 1 capsule every morning initiated 1/29/2023. A CCP titled alteration in physical function related to Resident #47's CVA with hemiplegia to the left dominant side and paraplegia was initiated and not reviewed since 6/4/2022. A CCP titled bowel incontinence related to CVA with hemiparesis initiated 12/27/2018 documented the last review date as 6/4/2022. An interview was conducted on 8/7/2023 at 12:10 PM with Registered Nurse Supervisor (RNS) #1, who stated CCPs are updated by the RN manager every 3 months. There is a report in the computer with the CCP review due dates. CCP revision is based on the MDS schedule. An interview was conducted on 8/7/2023 at 1:09 PM with the MDS Assessor, who stated the report printed out from the computer provides a schedule for reviewing and revising CCPs when the MDS s due. The MDS Department is responsible for making sure the CCPs are updated. An interview was conducted on 8/7/2023 at 1:15 PM with the Director of Nursing Services (DNS) who stated the nurse updates the CCP at least quarterly. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observations interview and record review, during a recertification survey on 07/31/2023- 08/07/2023 the facility did not ensure that services provided met professional standards of practice. This was evident for 2 (Resident #190 and #89) of 2 residents reviewed for feeding tube. Specifically, 1) Gastrostomy Tube (GT) placement and residuals were not checked prior to the administration of GT medications for Resident #190, and 2) Gastrostomy Tube (GT) placement and residuals were not checked prior to the administration of GT medications for Resident #89. The findings are: 1) Resident # 190 had diagnoses of gastrostomy status and dysphagia. The Minimum Data set 3.0 (MDS) assessment dated [DATE] documented Resident #190 was severely cognitively impaired. During a Unit 3L medication pass observation on 08/02/2023 at 9:30 AM, Licensed Practical Nurse (LPN) #2 administered medication to Resident #190 via GT after flushing the GT with lukewarm water. The nurse was not observed checking the GT for placement or residuals prior to administration of medication. Medical Doctor Orders dated 08/2023 documented check Resident #190 GT placement before and after medications. Check residuals, hold tube feeding 1 hour for residuals of 250 ml or greater. LPN #2 was interviewed at 9:47 AM on 08/02/23 and stated that the residuals need to be checked prior to the administration of medication to see if there is a buildup of fluid feedings in the stomach. 2.) Resident #89 had diagnoses of gastrostomy status and dysphagia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #89 was severely cognitively impaired. On 08/02/2023 at 10:26 AM, The Unit 3N Licensed Practical Nurse (LPN) #1 was observed checking Resident #89's GT placement with a stethoscope and then flushing the GT with water prior to medication administration. LPN #1 administered medication to Resident #89 via the GT and was not observed checking for residuals prior to administration. Medical Doctor Orders dated 07/13/2023 documented check Resident #89's GT for placement before and after any medications. LPN # 1 was interviewed on 08/02/2023 at 10:54 AM and stated that residuals need to be checked to see if there is a fluid buildup of feeds in the stomach. On 08/07/23 at 11:25 AM the Director of Nursing (DON) who stated checking for GT placement and residual is a basic nursing standard of practice. 10 NYCRR 415.11 (c)(3)(i)

Based on observation, record review, and interviews conducted during the Recertification and Complaint survey from 07/31/2023 through 08/07/2023, the facility did not ensure residents were adequately supervised to prevent smoking accidents. This was evidenced for 3 of 3 residents reviewed for Smoking (Resident #s 61, 71 and 163). Specifically, 1) Resident #71 was observed smoking unsupervised, 2) Resident #163 was observed smoking unsupervised, and 3) Resident #61 was observed smoking unsupervised. The findings are: The facility policy titled Smoking Program dated 10/2022 documented all smoking in the facility will be supervised and permitted only in designated areas and at designated times. Residents are not permitted to hold their smoking materials (cigarettes, matches, lighters, disposable/non-rechargeable e-cigarettes, pipes and other tobacco products). 1) Resident #71 had diagnoses of Cerebral infarction and muscle weakness. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #71 was cognitively intact and was a tobacco user. The following observations were made of the patio area: 08/03/23 11:21 AM sign on patio door thank you for observing our no smoking policy. Patio hours posted: Attention all residents, staff and visitors. The patio will be open from 9:00AM-9PM Monday - Sunday. the patio will be closed 9PM - 9AM daily and during inclement weather. During an observation on 08/02/2023 at 11:48 AM, there were 10 residents on the patio and 6 used cigarette butts were on the ground, 13 cigarette butts were in the garden area. Resident #49 was observed smoking a cigarette on the patio and extinguishing the cigarette on their shoe. On 08/03/2023 at 11:23 AM and 5:13 PM, Resident #61 was observed smoking on the patio and putting out the cigarette on their wheelchair armrest. Resident #71 had a cigarette in their mouth and had another resident light their cigarette for them with a lighter. The Security Supervisor was observed making rounds and saw Resident #71 with cigarettes smoking on the patio. Resident # 9 was observed smoking on the patio and tossing the cigarette on the concrete patio floor. There were multiple cigarette butts on the floor. The Comprehensive Care Plan related to Resident #71's smoking initiated 05/20/2020 documented the resident will be provided with supervision to smoke in designated smoking areas. The Smoking Evaluation dated 1/11/2023 documented Resident #71 was a smoker and cannot light their own cigarette. The Care Plan Notes for Activities dated 5/23/2023 documented Resident #71 was complaint with the smoking policy and was a safe smoker monitored by staff during smoking sessions. On 08/03/2023 at 12:11 PM, the Recreation Aide (RA #2) was interviewed and stated they monitor the smoke room. They have not noticed residents smoking on the patio. The smoke room is the only designated smoke area. On 08/04/2023 at 09:32 AM, the 4L Recreation Aide (RA #3) was interviewed and stated they have a list of safe and unsafe smokers. They noticed residents smoking on the patio area yesterday. The resident who was noticed smoking on the patio was asked if they would like to come to smoke room and the resident declined. They reported this to their supervisor the director of recreation yesterday. If they notice residents smoking outside the smoke room, they do not document this anywhere. On 08/04/2023 at 03:28 PM, Certified Nursing Assistant (CNA) # 7 was interviewed and stated Resident #71 smokes in the smoke room downstairs. Resident #71 is alert and can hold onto their own cigarettes. Sometimes CNA #7 notices Resident #71 smoking on the patio even though they know they are not supposed to. They would tell nurse in charge or the recreation person if they see residents smoking outside the smoke room. On 08/03/2023 at 01:01 PM, the Security Supervisor was interviewed and stated that they do rounds and observe the patio area. If they see residents smoking in the area, they will go and talk to them and let administration know and they do not usually they make an entry in the security log. The designated smoking area is the smoking room. On 08/03/2023 at 12:03 PM, the Assistant Director of Nursing (ADON) was interviewed and stated smoking materials should be kept in the smoking room. 45349 2) Resident #163 had diagnosis of tobacco use. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #163 was cognitively intact. On 8/3/23 at 10:25 AM, Resident #163 was observed smoking, unsupervised, around the side of the facility building, in a corner in front of a church building on the property grounds. Resident #163 was observed putting their cigarette out on the concrete ground. Resident #163 was interviewed about their smoking materials, and they stated that their cousin buys supplies, and they keep cigarettes and a lighter in their room. They further stated they also go to the smoke room sometimes, but the room is small. A Smoking Evaluation dated 1/12/2023 documented Resident #163 is a smoker and can light their own cigarette. A comprehensive care plan (CCP) titled resident is a smoker was created on 1/12/23 and documents the goals of Resident #163 will demonstrate compliance with smoking policy. 3) Resident #61 had a diagnosis of tobacco use. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #61 was cognitively intact. During an observation on 8/3/2023 at 10:17 AM, Resident #61 was on the patio smoking and put the cigarette out in between their two fingers. Resident #61 then re-lit the cigarette and continued smoking. A Smoking Evaluation dated 2/13/2023 documented Resident #61 was a smoker and can light their own cigarette. There was no documented evidence a Comprehensive Care Plan (CCP) related to smoking was in place for Resident #61 prior to 8/1/2023. An interview was conducted with Licensed Practical Nurse (LPN) #8 on 8/4/23 at 9:32 AM, who stated if they find cigarettes or a lighter on a resident, they will take it away and give to the social worker, who will then come and counsel the resident. An interview was conducted on 8/4/2023 at 10:47 AM with the Director of Recreation (DOR) who stated there is a designated smoking area/scheduled time. All smokers must come into the room to smoke. Smoking supplies are turned in to recreation and are kept in the locked cart in a locked room. Recreation monitors the smokers. If they see unsafe smoking, they report to the DOR who then reports to Nursing. The DOR discusses the smoking rules at resident council. The residents that are smoking in the patio are counseled about the designated smoke room and asked to turn in their smoking materials and sometimes they refuse. If the DOR finds out where the resident is getting supplies from, family and social work are informed. The DOR has never seen anyone smoke outside. An interview was conducted with the Administrator on 8/7/2023 at 2:49 PM who stated they saw multiple residents regarding smoking on the patio and in-serviced staff to look out for the residents. The resident(s) who were caught smoking signed contracts and have a disciplinary process in place. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and staff interview conducted during the recertification survey, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident for the lobby and 4 (2N, 2L, 4N, and 4L) of 6 units. Specifically, flies were observed in the lobby and on the 2nd and 4th floors. The finding is: The following observations were made on the 2nd and 4th floor: On 07/31/2023 at 10:19 AM, a fly flying in room [ROOM NUMBER]. On 07/31/2023 at 02:28 PM, 1 fly noted flying in room [ROOM NUMBER] On 08/02/2023 at 09:51 AM, 1 fly flying by nurses' station on 4L unit. On 08/02/2023 at 10:35 AM, 1 flying nurses station landing on the shelf for the medical records on top edge. On 08/02/2023 at 10:43 AM, 1 dead insect on the floor in the middle by the lobby desk. On 08/01/2023 at 10:55 AM, 1 fly flying near room [ROOM NUMBER] on the 4 N unit. On 08/01/2023 at 10:13 AM, 1 fly landing on kiosk by room [ROOM NUMBER] on 4N unit. On 07/31/2023 at 03:43 PM, 1 fly flying into room [ROOM NUMBER]. On 07/31/2023 at 03:38 PM, 2 flies flying in the sitting area on the 4L unit On 08/01/2023 at 05:19 PM, 1 fruit fly in room [ROOM NUMBER]. On 08/02/2023 at 09:20 AM, 1 fruit fly noted flying into room [ROOM NUMBER] from hallway. On 08/02/2023 at 03:10 PM, 1 small dead insect ~ 1/4 inch still on room [ROOM NUMBER]-bathroom floor. On 08/02/2023 at 03:33 PM, 1 fly flying in 4L nurse's station. On 08/02/2023 at 03:00 PM, 1 fly flying in 4L nurses' station by the light facing elevator side of nurse station. On 08/03/2023 at 12:31 PM, 1 fly flying near resident room [ROOM NUMBER]. On 08/04/2023 at 09:20 AM, 1 fly flying in the nurse's station on 2 N unit on overhead light. On 08/04/2023 at 10:59 AM, 1 fly flying in the nurse's station on 2 N unit. no fly boxes on the unit. On 08/04/2023 at 11:09 AM, 1 fruit fly flying in nurses' station on the 2N unit. On 08/04/2023 at 12:45 PM, 1 fly on nurse's station monitor on 4N unit. On 08/04/2023 at 12:40 PM, 1 fly flying into the elevator opposite the patio. On 08/04/2023 at 03:21 PM, 1 fly flying by nurses' station on 4 L unit. On 08/07/2023 at 11:17 AM, 1 fly flying by nurse's station. On 08/07/2023 at 11:49 AM, 1 fruit flying nurses' station 4L unit. On 07/31/23 12:47 PM fly crawling on resident #166 leg while lying in bed in room [ROOM NUMBER]. On 07/31/2023 at 12:48 PM fly flying on water pitcher for resident #166. On 08/01/2023 at 10:20 AM fly noted in room landing on resident #166 cover sheet on bed while resident was in bed. 08/01/2023 at 12:20 PM, a fly was observed flying in room [ROOM NUMBER] and landing on the meat for beef stew while resident #166 was eating lunch. On 07/31/2023 at 04:29 PM, Resident #131 was interviewed and stated they don't leave their door open because they have flies. On 08/01/2023 at 10:22 AM, Resident #166 stated they notice a fly in their room, and this happens all the time. On 8/01/23 12:05 PM, Resident #59 stated it is summer and there is no control over the flies because of the weather. The Lobby floor Pest Control Log for the lobby was reviewed documented on 6/2/2023 that roaches and flies were in rehabilitation on the 1st floor ceiling. The 4th floor Pest Control book documented on 6/8/2023 flies were in room [ROOM NUMBER] and 406. On 08/07/2023 at 11:47 AM, Licensed Practical Nurse (LPN) #5 stated that during the summer flies come around but LPN #5 have not seen any. If they notice pests, they report it to maintenance and the pest control company comes and they do general cleaning in relation to pests. There have not been any recent complaints regarding flies. On 08/07/23 at 01:55 PM, an interview was conducted with the Director of Maintenance (DOM) who stated the pest control technician comes every Friday and housekeeping normally goes with them on their rounds. Housekeeping is in charge when pest control comes. The DOM has not noticed any flies in the building only outside the building. On 08/07/2023 at 02:48 PM, the Administrator was interviewed and stated the exterminator comes weekly on a minimum and prior to the survey they did come and did a thorough cleaning of the building due to the flies. 10 NYCRR 415.(5)(h)(1)

Based on observation, interview, and record review conducted during the recertification survey from 07/31/2023 to 08/07/2023, the facility did not ensure privacy and confidentiality of the residents' medical information was maintained. This was evident on two (Unit 4L and Unit 3L) of 6 Units and for 2 (Resident # 24 and Resident # 190) of 38 total sampled residents. Specifically, 1.) Licensed Practical Nurse (LPN) #2 left a computer screen with Resident #24's medical information open to public view, and 2.) Resident #190's room door was left open, and the resident was in public view during a Gastrostomy Tube (GT) medication administration. The findings are: 1.) Resident #24 had diagnoses of Myocardial Infarction (MI) and Diabetes Mellitus (DM). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident @24 was moderately cognitively impaired. During Unit 4L medication pass observation on 08/02/2023 at 8:41 AM, LPN #2 was observed in Resident #24's room with their back facing the medication cart. The computer screen containing Resident #24's identifying information was on the medication cart in the hallway in public view. LPN # 2 was interviewed on 8/2/2023 at 8:47 AM and stated they should have closed the computer screen to hide Resident #24's personal information. On 08/07/2023 at 08:25 AM, the Registered Nurse (RN) # 1, Unit Manager for Unit 4L, was interviewed and stated that their role is to ensure that nurses perform their duties. RN #1 makes unit rounds to observe for unattended medication carts. The nurses know not to leave the computer screen open due to the Health Insurance Portability and Accountability Act (HIPAA) that requires protection of patient information. Medications carts should not be left unattended. 2.) Resident #190 had diagnoses of Gastrostomy Status and Dysphagia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #190 was severely cognitively impaired and required the total assistance of 2 people for Activities of Daily Living (ADL). During Unit 3L medication pass observation on 08/02/2023 at 9:30 AM, Licensed Practical Nurse (LPN) #3 was in Resident #190's room administrating medication to the resident via GT with the room door open and Resident #190 in public view from the hallway. LPN #3 was interviewed on 08/02/2023 at 9:47 AM and stated a resident's door is to be closed to provide them with privacy when providing the resident care and treatment. On 08/07/2023 at 11:25 AM, the Director of Nursing (DON) was interviewed and stated it is a privacy and dignity concern when staff do not close residents' room doors when providing care, services, and treatments. 10 NYCRR 413.3(d)(1)(ii)

2.) During observation of the Unit 4L medication pass on 08/02/2023 at 8:41 AM, Licensed Practical Nurse (LPN) #2 entered Resident #24's room and had their back to the medication cart while 3 blister packs of medication were left unattended on top of the cart: Lithium 300 milligram (mg) give 1 by mouth twice a day; Perphenazine 2 mg by mouth 3 times a day and Plavix 75 mg by mouth daily. LPN #2 was interviewed on 08/02/2023 at 8:47 AM and stated they should not leave medications unattended on the medication cart as to avoid someone picking them up. On 08/07/2023 at 08:25 AM, the Registered Nurse (RN) Unit Manager # 1 stated they make rounds and observe the medication carts, if the nurses are performing their duties, and if the medication carts are left unattended. The nurses know not to leave medications unattended on the medication carts to avoid any accidents and to protect residents from accidentally taking them. 10 NYCRR 415.18(e)(1-4) 42101 Based on observation, record review, and interviews conducted during the Recertification survey from 7/31/2023 to 08/07/2023, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 (Unit 4L) of 6 units. Specifically, 1) 3 expired pneumovax vaccine vials in the medication refrigerator, an expired box of ibuprofen, and an expired bottle of Magnesium citrate in the medication room on 4L, and 2) 3 medication blister packs were left unattended on top of a medication cart on Unit 4L. The findings are: The facility policy titled Medication Storage dated 1/2019 documented expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. The facility policy titled Medication Administration dated 12/2019 documented during administration of medications, no medications are kept on top of the cart. The facility policy titled Storage and Discard Dating of Drugs and Biologicals dated 12/22/2022 documented drugs shall not be kept on hand after the expiration date on the label and no contaminated or deteriorated drugs shall be available for administration. 1) On 08/04/2023 at 03:56 PM, the 4 L unit medication room was observed with Licensed Practical Nurse (LPN) # 7 and the following was observed in the room cabinet: Magnesium citrate cherry flavor 10 oz with expiration date of 12/2022 (0516065 349 183016) and Ibuprofen 200mg (100 coated tablets - 1 box lot WJ21057) expiration date of 03/2023. In the medication room refrigerator 3 syringes (.5 ml) of Pneumococcal vaccine Polyvalent Pneumovax 23 with lot number Lot U034712 had an expiration date of 7/30/2023. On 08/04/2023 at 04:12 PM, an interview was conducted with LPN #7 who stated that they check medications every time they bring new meds, and they try to do as much as can with the medication room and this needs to be teamwork. They check the medication room once a week and they don't document it anywhere. LPN #7 is present at times when the pharmacy comes to check the medication room. On 08/04/2023 at 04:29 PM, an interview was conducted with Registered Nurse Supervisor (RNS) #4 who stated that they check the medication rooms once a week and they look at the temperature in the fridge and they did not notice any medications that were out of date in the medication room. The last time they looked at 4L unit was about 2 weeks ago when they checked the medication room, and they did not notice expired items. On 08/07/2023 at 12:51 PM. the Director of Nursing (DNS) was interviewed and stated they check the medication rooms monthly. Staff should be looking in the medication room to make sure there are no expired medications. Expired vials should be removed from the medication room. Biologicals medications (immunizations) should be checked by staff for the expiration date prior to administration. On 08/07/2023 at 02:03 PM, The Administrator was interviewed and stated that the facility does their own inspection of medication room. An internal inspection is done to be on top of everything and the facility contacted a pharmacy for an extra pair of eyes to do an audit as well.

Based on observations, interviews, and record review conducted during the Recertification from 7/31/2023 to 8/7/2023, the facility did not ensure a resident received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was evident for 1 (Resident #202) of 8 residents reviewed for Activities of Daily Living (ADL), out of an investigative sample to 38 residents. Specifically, Resident #202 was observed with unkempt, disheveled, matted hair. The findings are: The facility policy titled ADL Personal Hygiene dated 10/2021 documented hair care should be provided to resident as needed or by appointment at hairdressers. The Certified Nursing Assistant (CNA) should report to the Licensed Nurse any concerns/observations during care. Resident # 202 had diagnoses of Anemia and Anorexia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #202 was moderately cognitively impaired and required the physical assistance of extensive assistance of two people for personal hygiene. On 08/01/2023 at 03:03 PM, 08/02/2023 at 08:48 AM, 08/02/2023 at 08:48 AM, 08/03/2023 09:14 AM, 08/04/2023 at 08:58 AM, 08/04/2023 at 02:35 PM, and 08/07/2023 at 09:14 AM, Resident #202 was observed with disheveled and unkempt hair, matted, stuck together and in two clumps. 08/07/23 at 09:25 AM, Registered Nurse (RN) #3, Unit Manager, searched Resident #202's room and was unable to locate any grooming materials including shampoo and a comb or brush. The Comprehensive Care Plan (CCP) related to ADLs initiated 4/24/2023 and last updated 7/6/2023 documented Resident #202 required staff assistance to provide bathing products and setup and cueing for bathing. There is no documented evidence Resident #202 was provided with grooming ADL care to address matted hair. There is no documented evidence Resident #202 refused grooming services. On 08/03/2023 at 11:04 AM, an interview was conducted with CNA #3 who stated Resident #202 required supervision with ADL care and did not refuse care. Resident #202 can fix their own hair and did not request assistance with their hair care. CNA #3 was unable to locate a comb or brush in Resident #202's room, and had no response if resident was given grooming materials for their hair or assisted with grooming. On 08/04/2023 at 02:18 PM, CNA #2 was interviewed, and stated Resident #202 sometimes refuses showers, and the CNA informs the nurse on the unit when the resident refuses. Resident #202's hair is being washed by CNA #2. Resident #202 was admitted to the facility with matted hair and does not want anything done to it. Resident #202 refuses to fix their hair. The nurse is aware that Resident #202's hair is matted. On 08/04/23 at 02:25 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4 who stated the CNA did not report Resident #202 is refusing ADL care, including combing of hair. Resident #202 does not like people touching them. LPN #4 stated they offered to get Resident #202's hair done but the resident refused. The Unit Manager (UM) should be aware but is on vacation. LPN #4 stated they are not sure what to do to fix this. On 08/07/2023 at 09:18 AM, an interview was conducted with Registered Nurse (RN) #2 who stated they are covering for the UM on vacation. RN #2 became aware of Resident #202's matted hair while covering. If the CNA sees a resident with matted hair, the CNA reports to the Nurse, the Nurse reports to the Unit Manger and the UM will get in contact with the family and explain the matted hair and get permission to cut the hair. RN #2 stated If the family refuse, then will meet with the team and put care plan in place, and document refusal. RN #2 stated they will continue to reoffer and contact family quarterly and document the family response. RN #2 stated the resident should have a comb and a brush in room because all residents on admission is given a welcome kit which includes a basin, comb, brush, body wash deodorant toothbrush and tooth paste to groom. RN #2 was unable to locate a comb or brush in resident's room. RN #2 was unable to explain if resident refuse care. On 08/07/2023 at 02:53 PM, the Director of Nursing Services (DNS) was interviewed and stated the nurses and unit managers monitors the CNA and the CNA must report to the nurse if three is an issue or concern. Resident behavior will be care planned and refusal of care will be documented. 10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews conducted during the Recertification survey from 7/31/2023 to 8/7/2023, the facility did not ensure person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's concerns. This was evident for 1 (Resident #61) of 5 residents reviewed for accidents. Specifically, a CCP related to smoking was not developed and implemented for Resident #61, a smoker. The findings are: The facility policy titled Care Plans - Comprehensive dated 10/2019 documented a CCP that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident # 61 had diagnoses of coronary artery disease and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #61 was cognitively intact. A Nursing Smoking Evaluation dated 2/13/2023 documented Resident #61 was a smoker, and the plan of care was to ensure Resident #61 was safe while smoking. A Smoking Rules and Safety Agreement was signed by Resident #61 on 2/13/2023. There was no documented evidence a CCP related to smoking was created and implemented for Resident #61 prior to 8/1/2023. An interview was conducted on 8/7/2023 at 2:16 PM with the Assistant Director of Nursing Services (ADNS) who stated Resident #61 began smoking on 2/13/2023 but the CCP related to smoking was not created until 8/1/2023. An interview was conducted on 8/7/2023 at 2:19 PM with the Director of Nursing (DNS) who stated they are not familiar with the medical record and the CCP is not active until it has been created in the system. 10 NYCRR 415.11 (c)(1)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 355), the facility failed to ensure that a resident's care plan was reviewed and revised to reflect the resident's status. This was evident in 1 of 2 residents sampled (Resident #1). Specifically, Resident #1's care plan dated 08/20/2021, documented that Resident #1 walked in room and corridor with extensive assist of one staff. A Therapy-Rehabilitation to Nursing ADL Communication note dated 04/27/2022 documented that Resident #1 required supervision to walk-in room and corridor. Resident #1 also required supervision for Locomotion on and off unit. On 05/22/2022 at 5:15PM, the facility's surveillance video recording showed Resident #1 ambulating independently and without unsteady gait. Findings are: The facility policy and procedures titled Care Plan dated 10/2021 documented a comprehensive, person-centered care plan that includes measurable objectives and time- tables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident' conditions change. The interdisciplinary team reviews and updates the care plan. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 04/22/2022 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score 04/15 indicating severely impaired cognition. Resident #1 required extensive assistance of one person with bed mobility and transfer. The resident required extensive assistance of two plus persons for walking in room and extensive assistance of one-person for walking in corridor. Resident also required total assistance of one-person for locomotion on and off the unit. The MDS also documented that Resident #1 normally used a walker and wheelchair as mobility devices. A review the Activity of Daily Living (ADL) Comprehensive Care Plan dated 08/30/2021, documented that Resident #1 required total assistance of one staff for locomotion on and off the unit (Resident does not participate in activity at all). Resident #1 required extensive assistance of one staff for waling in room and corridor (staff physically Lift, Bear, Hold or Support any of the resident's weight-Example: resident may lean on staff, staff may lift or hold gait belt, staff may walk arm in arm to support trunk or extremity weakness). A review of a Documentation Survey Report dated March-April 2022 documented that Resident #1 walked in room and corridor with extensive assistance of one staff (Staff physically lift, bear, hold or support any of the resident's weight - Ex: resident may lean on staff, staff my lift, or hold gait belt, staff may walk arm in arm to support trunk or extremity weakness). Also documented, Adaptive Device: Out of bed with wheelchair with cushion one person assist. Resident #1 required total assistance of one staff for Locomotion on and off unit (Resident does not participate in activity at all). A Therapy: Rehabilitation to Nursing ADL Communication note dated 04/27/ documented that Resident #1 required supervision - no set up help required, for walking in room and corridor. Resident #1 required supervision for Locomotion on and off unit (staff provide one or many verbal prompts/cues to resident). Also documented, Resident #1 was independent with bed mobility and does not require any assistance. During an interview on 05/25/2022 at 11:15AM, Certified Nursing Assistant (CNA) #1 stated that Resident #1 walks independently and does not require staff assistance. Stated Resident #1 does not walk with unsteady gait and does not require walker or wheelchair. CNA #1 stated that Resident #1 requires one staff to assist with grooming and toileting. CNA #1 stated that Resident #1 preferred to go downstairs to smoke, then return to the unit at 8:00PM. CNA #1 stated that stated that it was Resident #1's regular routine leave the unit independently and returns to the unit independently. During an interview on 05/25/2022 at 5:00PM, Nursing Supervisor (NS) #1 stated that Resident #1 walked independently and goes downstairs to smoke and read, then comes back to the unit. NS #1 reported that he/she has never observed Resident #1 with unsteady gait or the resident walking with assistance from staff. NS #1 stated that he/she is responsible for updating Resident #1's care plan and the CNA accountability record. NS #1 stated that he/she did not review and revised Resident #1's care plan and the CNA accountability record to reflect on the resident's status. During an interview on 05/26/2022 at 6:30PM, Licensed Practical Nurse (LPN) #1 stated that since Resident #1 was transferred to the unit, the resident has been ambulating independently. LPN #1 stated that he/she has been working with Resident #1 and never observed the resident using any assistive devices. LPN #1 stated that Resident #1 does not have unsteady gait and does not require any assistance from staff during ambulation. During an interview on 05/27/2022 at 11:00AM, Physical Therapist (PT) #1 stated Resident #1 completed physical therapy on 04/27/2022 and that Resident #1's Activity of Daily Living (ADL) status had changed. PT #1 stated Resident #1's task was updated to walking with supervision. PT #1 stated the nursing department should have updated resident's care plan and the CNA Accountability record with new ADL status. 415.11 (C)(2)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 355), the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the resident's status. This was evident in 1 of 2 residents sampled. (Resident #1). Specifically, the Minimum Data Set (MDS) dated [DATE] documented that Resident #1 required extensive assistance of two plus persons for walking in room and extensive assistance of one-person for walking in corridor. Resident also required total assistance of one-person for locomotion on and off the unit. The MDS also documented that Resident #1 normally used a walker and wheelchair as mobility devices. Staff interviews revealed that Resident #1 ambulates on and off the unit independently and does not require assistive devices. Findings are: The facility policy and procedure entitled Minimum Data Set (MDS) Assessment Coordinator dated 05/2019 documented it is the policy of the facility to assess and code the resident's functional status accurately for coding of section GG of the MDS by gathering resident information from a variety of sources including, but not limited to: direct interview of resident and or family, review of medical record and direct observation of resident performance. By utilizing an interdisciplinary team approached the MDS will be encoded with the resident's usual performance. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review the Activity of Daily Living (ADL) Comprehensive Care Plan dated 08/30/2021, documented that Resident #1 required total assistance of one staff for locomotion on and off the unit (Resident does not participate in activity at all). Resident #1 required extensive assistance of one staff for waling in room and corridor (staff physically Lift, Bear, Hold or Support any of the resident's weight-Example: resident may lean on staff, staff may lift or hold gait belt, staff may walk arm in arm to support trunk or extremity weakness). The Quarterly Minimum Data Set (MDS, a resident assessment tool) dated 04/22/2022 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score 04/15 indicating severely impaired cognition. Resident #1 required extensive assistance of one person with bed mobility and transfer. The resident required extensive assistance of two plus persons for walking in room and extensive assistance of one-person for walking in corridor. Resident also required total assistance of one-person for locomotion on and off the unit. The MDS also documented that Resident #1 normally used a walker and wheelchair as mobility devices. A review of a Documentation Survey Report dated March 2022 documented that Resident #1 walked in room and corridor with extensive assistance of one staff (Staff physically lift, bear, hold or support any of the resident's weight - Ex: resident may lean on staff, staff my lift, or hold gait belt, staff may walk arm in arm to support trunk or extremity weakness). Also documented, Adaptive Device: Out of bed with wheelchair with cushion one person assist. Resident #1 required total assistance of one staff for Locomotion on and off unit (Resident does not participate in activity at all). During an interview on 05/25/2022 at 11:15AM, Certified Nursing Assistant (CNA) #1 stated that Resident #1 walks independently and does not require staff assistance. Stated Resident #1 does not walk with unsteady gait and does not require walker or wheelchair. CNA #1 stated that Resident #1 requires one staff to assist with grooming and toileting. CNA #1 stated that it was Resident #1's regular routine to leave the unit independently, to smoke, and returns to the unit independently at 8:00PM. During an interview on 05/25/2022 at 5:00PM, Nursing Supervisor (NS) #1 stated that since Resident #1 was transferred to the unit, the resident has been walking independently. NS #1 stated that Resident #1 goes downstairs to smoke and read, then comes back to the unit. NS #1 reported that he/she has never observed Resident #1 with unsteady gait or ambulating with assistance from staff. During subsequent interview with NS #1, on 06/09/2022 at 1:45PM, NS #1 stated that Resident #1 was transferred to the unit on 10/18/2021 and was walking independently without assistive devices. During an interview on 05/26/2022 at 6:30PM, Licensed Practical Nurse (LPN) #1 stated that since Resident #1 has been on the unit (03/2022), the resident has been ambulating independently. LPN #1 stated from he/she has been working with Resident #1, he/she has never observed the resident using any assistive devices. LPN #1 stated that Resident #1 does not walk with unsteady gait and does not require any assistance from staff during ambulation. During subsequent interview with LPN #1 on 06/09/2022 at 2:35 PM, LPN #1 stated that he/she has been working on the third floor for [AGE] years. LPN #1 stated he/she was on the unit when Resident #1 was transferred to the unit and that the resident was not transferred with any assistive devices. During an interview on 05/26/2022 at 9:35AM, Minimum Data Set Coordinator (MDSC) #1 stated that he/she looked at different factors for coding resident's functional status. MDSC #1 stated that he/she looked back 7 days on the 3 shifts to assesses Resident #1's performance. MDSC #1 stated that Resident #1 can perform Activities of Daily Living (ADL) independently in the morning and then in the evening and at night, performs at a different level. MDSC #1 stated that he/she has never observed Resident #1's performance. Stated that he/she coded Resident #1's most dependence based on nursing tasks documented. MDSC #1 stated that when he/she completed the MDS quarterly assessment April 2022, nursing was documenting that Resident #1 was using a wheelchair. 415.11(b)